Quiz 1 Flashcards
What substance is contained within the stem of the Mirena coil?
Levonorgestrel 52mg released at 20 micrograms per day.
List 3 contraindications to the use of this form of contraception.
Pregnancy Unidagnosed vaginal bleeding Previous ectopic pregnancy (relative CI) Past history of Pelvic Inflammatory Disease (relative CI) Structural cardiac abnormality Known HIV infection Genital malignancy Nulliparity (relative CI)
List two non-contraceptive benefits of the Mirena coil.
85% amenorrhoea at 6 months, leading to increase in Hb and serum ferritin
Decrease in risk of PID due to progestagenic effect on cervical mucous & endometrium
Lower ectopic risk compared to standard copper IUCD’s
Reduction in size of uterine fibroids
May be used as progestogen component of HRT
Describe your management of a patient who presents with the strings no longer visible at the external cervical os.
Ultrasound scan to check if IUS is intrauterine as a first investigation.
If intrauterine, consider whether it needs to be removed - does the patient wish pregnancy or need a change of IUS. If so, attempt removal with IUCD retriever, otherwise will need removal under anaesthetic or outpatient hysteroscopy.
If not intrauterine, AXR to check if it has perforated (as opposed to fallen down the toilet!). Then laparoscopy to retrieve.
How would you manage a patient using this form of contraception who presents with seven weeks amenorrhoea, tender breasts and nausea and vomiting in the morning?
Pregnancy test.
Transvaginal scan to detect if pregnancy intrauterine or ectopic (ectopic risk is 1/5 in IUS failures) - may need serial serum hCG’s if too early to descriminate.
Remove IUS if possible (miscarriage risk reduced from 50% to 20% following removal).
Explain risks if pregnancy continues with IUS in place - increased risk of preterm delivery and chorioamnionitis, and unknown teratogenicity risk of levonorgestrel release.
What is the main indication for ICSI?
Severe male factor infertility
What are three possible side effects of ICSI/IVF?
Multiple pregnancy
Ovarian hyperstimulation syndrome
Infection following TV USS-directed egg retrieval.
Increased risk of miscarriage
Increased risk of ectopic pregnancy
Psychological effects of intensive treatment with high failure rate
Increased risk of Y-chromosome abnormalities in male offspring conceived via this technique
What is the average quoted success rate?
About 20% per cycle - better for younger women and much worse for older. The main determinant is the age of the eggs used for IVF
What is the name of the governing body which oversees reproductive treatments?
Human Fertilisation and Embryology Authority (HFEA)
How may Down’s syndrome be detected antenatally? Name 2 screening tests and two diagnostic tests.
Screening: Serum screening (double or triple test) or first trimester nuchal translucency (NT) scan
Diagnosis: Amniocentesis or Chorion Villus Sampling (CVS)
Serum screening is carried out between 15-19 weeks and gives an indication if a woman is high or low risk.
NT screening in the first trimester will detect 80% of Down’s syndrome, but this is a first trimester screening test and 25% of Down’s pregnancies will spontaneously miscarry between 10 and 15 weeks. Thus in part NT screening may convert pregnancies that are destined to miscarry anyway into terminations of pregnancy.
What are the sensitivity and false positive rates for the most widely available screening method?
Sensitivity is 60%
False positive 5%
1 in 20 women who have serum screening will be told they are high risk and advised to undergo invasive testing - even though the vast majority of these babies will not have Down’s. It is important that this is conveyed in the counselling that takes place prior to serum screening.
What are the risks of miscarriage in confirming the diagnosis during the antenatal period?
CVS - 1-2%
Amnio - 0.5-1%
If a couple chose termination of pregnancy following prenatal diagnosis at 16 weeks gestation, what method would be used?
Medical termination of pregnancy with mifepristone & misoprostol most likely.
Dilatation & evacuation a possibility where local expertise exists up to 18 weeks gestation
How would a patient typically present with genital herpes?
Pain, superficial dysuria, vulval ulceration, discharge, retention of urine, apareunia.
How is the diagnosis of herpes made in practice and how may it be confirmed?
The diagnosis is made clinically but may be confirmed by viral culture from the lesions.
What is the treatment for genital herpes?
Antiviral treatment, e.g. Acyclovir 200mg 5x per day
Local anaesthetic gel (lignocaine 1%)
Broad spectrum antibiotics if ulceration severe to prevent secondary infection (eg. trimethoprim 200mg BD)
Topical acyclovir is not used for genital herpes
What needs to be discussed with a woman who presents with genital herpes for the first time at 37 weeks gestation?
Caesarean section to prevent overwhelming neonatal herpes. This is advised if the primary attack occurs any time after 34 weeks, as asymptomatic viral shedding is possible for some time after a primary attack.
If this was a secondary attack, caesarean section would be offered if lesion are present at the time of labour (although the risk of neonatal disease is much lower in this case).
It is also important to discuss screening for other genital infections and refer to GUM clinic for counselling & contact tracing.
When would you use a ring pessary/shelf pessary?
Genital prolapse (no extra marks for listing all the different types!) when unfit, unsuitable or patient declines surgery Pregnancy and the puerperium when prolapse occurs. The tissues will retract after delivery Prior to surgery to allow healing of a decubitus ulcer related to a procidentia
Give three side effects of using pessaries for prolapse
Discomfort
Retention of urine
Vaginal ulceration
Rarely carcinoma of the vagina
How often should pessaries be changed and why?
6-monthly to check for vaginal ulceration
What are the risk factors for osteoporosis?
Menopause Premature ovarian failure Chronic steroid administration GnRH treatment Prolonged heparin treatment Family history of osteoporosis Thin stature Smoking
What are the potential side effects to HRT?
Unwanted resumption of menses
Venous thromboembolism
Breast cancer
Oestrogenic or progestogenic side effects
What are the benefits of HRT other than preventing osteoporosis?
Psychological benefits Less genital tract atrophy Reduced vasomotor symptoms Reduced risk of Alzheimer's disease Note, HRT has now been proven not to be protective against ischaemic heart disease, and is contraindicated in women with pre-existing IHD.
Describe four methods of administration of HRT to a woman with an intact uterus.
Oral sequential (monthly & quarterly bleed) Oral combined continuous Patches Gel Oral oestrogen & Mirena IUS.
What are the possible complications of LLETZ?
Haemorrhage - primary & secondary Infection Cervical stenosis Profuse discharge Incomplete excision
LLETZ does not cause cervical incompetence - the risk is with cold knife cone biopsy, which is carried out under general anaesthetic.
What advice should you give a woman after LLETZ?
Warn her that she will experience some discharge for a couple of weeks, but to attend her GP if this becomes offensive. She will lose a brown discharge in one to two weeks time as the scab comes off.
Avoid tampons and sexual intercourse for up to four weeks. The timing of this seems to vary between clinics.
What are the risk factors for cervical cancer?
Smoking HPV 16, 18, 31, 33, 34 Multiple sexual partners Early age at first intercourse HIV infection Immunosuppression
What criteria should be fulfilled for an instrumental delivery?
Full dilatation
Operator experienced with instrument
Ruptured membranes
Maternal consent obtained
Head engaged (1/5 palpable per abdomen or less)
Presenting part at the level of the ischial spines or lower on vaginal examination
Adequate analgesia
Definite fetal position identified
Uterus contracting
+/- empty bladder - not necessary if recently been done, especially for ventouse
When should a forceps delivery be favoured over a Ventouse delivery?
Operator experience Aftercoming head during an assisted breech delivery At caesarean section Prematurity (<34 weeks gestation) Face presentation Excessive caput secundum When speed of delivery is important Rotational delivery where the fetal head is asynclitic or poorly flexed
What is the first line of management for PPH?
IV access
FBC & clotting screen
Crossmatch at least two units of blood
Check the placenta is complete
Massage the uterus to ensure it is contracted
Give oxytocics (oxytocin or ergometrine)
Check for genital tract lacerations and repair them
What are the causes of PPH?
Trauma
Tissue - placenta
Tone - atonic uterus
Thrombin - clotting problems
The placenta and membranes are complete and there is no trauma to the lower genital tract, but she continues to bleed. What do you do now?
Bimanual compression of the uterus
Carboprost (Hemabate, PGF2-alpha) by direct myometrial injection if uterus remains atonic
Examination under anaesthetic
After ensuring that the uterus is empty, other surgical procedures must be considered if the bleeding does not stop, including laparotomy, a uterine bracing suture, internal iliac ligation or hysterectomy.
What components are considered when performing a biophysical profile (BPP)?
CTG Liquor volume Fetal gross body movements Fetal tone Fetal breathing movements
List 5 obstetric conditions where the above investigations might be useful?
ntrauterine growth restriction Preeclampsia Decreased fetal movements Decreased liquor volume Twin pregnancy Diabetes mellitus
What are the non-contraceptive benefits of COCP?
Reduction in menstrual flow. Reduced risk of pelvic inflammatory disease. Reduced risk of functional ovarian cysts Reduced risk of benign breast cysts Reduced risk of ovarian cancer. Cycle regulation Improvement of dysmenorrhoea.
What are absolute contraindications to COCP?
Vascular history - stroke, hypertension, myocardial infarction or transient ischaemic attacks
History of thromboembolism: eg. deep vein thrombosis or pulmonary embolism
Carcinoma of the breast or endometrium
Active liver disease
Heart disease
Pregnancy
Known prothrombotic condition, such as ATIII deficiency
Complex migrane
What are side effects to COCP?
Development of hypertension Increased risk of thromboembolism Increased risk of hepatic tumours Spotting in the early months Weight gain - due to increased appetite Alteration of libido - usually reduced
A patient on COCP is going to undergo surgery. What should you advise?
Continue the COC’s - for minor surgery the excess risk of thromboembolism is not significant. For major surgery, the pill should be stopped, ideally 6 weeks beforehand.
If she does stop the pill, then ensure a reliable alternative arranged.
What is Fitz-Hugh-Curtis syndrome?
perihepatitis due to intraperitoneal spread of a chlamydia pelvic infection
What symptoms may be present in PID?
Right sided hypochondrial pain
Offensive vaginal discharge - although this is less common with chlamydia than the vaginal infections.
Patient generally unwell due to systemic infection
Nausea or vomiting
What are the sequelae of PID?
Infertility Chronic pelvic pain Dyspareunia Pelvic adhesions Menorrhagia
How are vaginal cones used?
By placing the weighted cones into the vagina & contracting the pelvic floor muscles to hold it in place, pelvic floor tone can be increased. The weight or time held in place is gradually increased.
What investigations are necessary before surgery for urinary stress incontinence?
Midstream urine culture
Urodynamics (cystometry)
What are the side effects of incontinence surgery?
Poor stream/voiding difficulties
UTI
Complete urinary retention requiring intermittent self-catheterisation
Detrusor instability
Enterocele
Retropubic haematoma/abscess following Burch colposuspension
Infected/fistulous rectus sheath sutures following Stamey
List 4 predisposing factors to urinary stress incontinence.
Vaginal delivery (especially forceps & prolonged active second stage)
Large babies
Obesity
Smoking
Chronic obstructive airways disease (COPD)
Menopause
What blood tests should be done to test for PCOS?
Follicular-phase LH/FSH
Serum prolactin
Serum androgens
Sex hormone binding globulin (SHBG)
Timed gonadatrophins in the early follicular phase of the cycle are required, due to physiological mid-cycle surges. An abnormally raised LH is indicative of PCOS and a LH:FSH ratio greater than 3 is also suggestive of the condition. Prolactin is mildly raised in 15% of cases of PCOS. Serum androgens are raised and SHBG is depressed, leading to higher levels of free testosterone.
What are the diagnostic criteria for PCOS?
Hirsutism (clinical or biochemical)
Polycystic appearance of ovaries on ultrasound
Irregular periods more than 5 weeks apart
What is the treatment for PCOS is a patient is not trying to conceive?
The combined contraceptive pill would be expected to regulate her menstrual cycle. It is important that she has at least 4 periods per year to ensure protection from endometrial hyperplasia. Oestrogen levels are usually higher than normal due to excess peripheral conversion of androstendione to oestriol in fat. The absence of monthly menstruation means that endometrial hyperplasia is a risk and if untreated can lead to endometrial cancer.
How may a patient with PCOS be helped to conceive?
Clomiphene citrate
Laparoscopic ovarian diathermy (drilling)
Controlled ovarian stimulation with gonadotrophins
Insulin-sensitising drugs such as metformin
IVF
What are the long term complications of PCOS?
Infertility
Increased risk of diabetes
Increased risk of hypertension and ischaemic heart disease
What are the risks of Caesarean section?
Immediate: primary haemorrhage, damage to bowel, bladder or ureters, anaesthetic risks
Early: Infection (chest, urinary, endometritis, wound), DVT/PE, secondary haemorrhage
Late: Increased risk of needing a repeat caesarean, adhesions leading to a greater risk of tubal infertility or chronic pelvic pain, adhesions sticking bladder to the uterus, making repeat sections or future hysterectomy more risky, increased risk of placenta praevia/accreta in the next pregnancy.
